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by John Coggin

JohnCogginHeadshotI’m going to tell you a secret. I am tired of hearing about the rural/urban divide.

On one hand, the attention being paid to rural right now is wonderful! There are many rural areas of our state that have been struggling for a very long time – and that struggle has been dramatically compounded by the devastation from Hurricane Florence in eastern North Carolina. I relish any focus we can bring to building capacity, overcoming generational poverty, and advancing equity for those communities.

At the same time, though, I maintain that we are not nearly as divided as the rhetoric around the rural/urban divide makes us seem. Over the past year I travelled 8,457 miles to meet with 1,600 community leaders in all 80 counties we serve. When I talk with people about what really matters, the messages I hear are just about the same. We all want our children to have a quality education that prepares them for good jobs. We want our communities to be safe, healthy,  supportive, and full of opportunities. These are not rural issues, or urban issues – they are unifying issues that we can work together to solve.

One of these unifying issues is access to affordable health insurance, which not only helps keep our workforce healthy but also helps stabilize the finances of families and the health sector. Stable health systems are particularly important in our 80 rural counties, and not just for the care they provide to patients. Over 179,000 rural North Carolinians are employed by the health industry in jobs that pay $2.3 billion in taxable wages*. The health sector plays a vital role in helping our people and economies thrive.

How do we insure more people? We want to find the right policy solution for North Carolina. Several options have been presented at the General Assembly, from outright expansion of Medicaid to Carolina Cares, the 2017 proposal advanced by a group of Republican House members. Whatever the exact solution, closing the health insurance gap is possibly the single most significant action that could be taken to bolster rural health care in our state.

A new report from Georgetown University and the Sheps Center at UNC proves that the solution for rural North Carolina would also be a tremendous help for our urban areas. At first glance, the report might seem to reinforce stereotypes about a rural/urban divide. This study explores differences in the rates of uninsured adult citizens with low incomes in rural and urban areas. Across the nation, states like North Carolina that have chosen not to expand Medicaid are seeing significantly higher numbers of uninsured citizens. Uninsured rates are even higher in rural areas than in metro areas. States that did not expand have an average of 32% of rural low-income adult citizens with no insurance, compared to 26% in cities.

North Carolina is no exception to the rule – but our numbers raise some interesting questions. Rural uninsured rates are higher, but not by much. Low-income citizens in NC cities are uninsured at a 25% rate, and in rural areas at a slightly higher 29% rate. Compare that to Florida, where the urban/rural divergence is much greater – 24% uninsured in urban areas, and 37% in rural areas.

This near-parity among the uninsured in rural and urban North Carolina should serve as a rallying cry to insure more people, no matter where they live in our state. The economic case for increasing access to affordable insurance is abundantly clear in a rural area where one hospital closing could send shock waves throughout an entire county. But the stability generated by having more people insured is just as important in urban economies.

Yes, varying dynamics of urban and rural communities often mean that tactics for addressing problems may need to differ. But many of the underlying challenges we face are the same. If we could concentrate on finding solutions to shared challenges, perhaps we would hear less about a “rural/urban divide” and more about planning for a bright future for all of North Carolina.


Want to be a part of finding the right solution for closing the coverage gap? Join the Rural Center at one of our upcoming Zero Barriers Policy Roundtables, being held in October at seven locations around the state. We’ll be asking for your input on what policies we need to tackle in 2019 around rural health care, broadband, and small business development. Registration is free but required. Sign up today!  

*NC Department of Commerce Quarterly Census of Employment and Wages (QCEW), 2015.

John Coggin is Director of Advocacy at the NC Rural Center.


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